This update reviews the current situation and the surveillance and
diagnostic recommendations for avian influenza A (H5N1). The recommendations
for avian influenza A (H5N1) remain at the enhanced level established in
February 2004. As detailed in the recommendations below, vigilance in the
clinical setting for avian influenza (H5N1) requires that health care
providers consistently obtain international travel and other exposure risk
information for persons who have specified respiratory symptoms.

Current Situation

On August 12, 2004, the Vietnamese Ministry of Health officially reported to
the World Health Organization (WHO; see
http://www.who.int/csr/don/2004_08_12/en/) three human deaths from
confirmed avian influenza H5 infection. Additional tests are needed to
determine whether the virus belongs to the same H5N1 strain that caused 22
cases (15 deaths) in Vietnam and 12 cases (8 deaths) in Thailand earlier
this year.

Cambodia, China, Indonesia, Japan, Laos, South Korea, Thailand, and Vietnam
were previously affected by widespread H5N1 outbreaks in poultry during
early 2004. At that time, more than 100 million birds either died from the
disease or were culled (killed) in efforts to contain the outbreaks. Human
cases (34 in all) were reported only in Thailand and Vietnam. The last case
officially confirmed and reported to WHO by Vietnam occurred in February
2004.

Beginning in late June 2004, however, new lethal outbreaks of highly
pathogenic avian influenza A (H5N1) among poultry were reported to the World
Organization for Animal Health (OIE) by China, Indonesia, Thailand, and
Vietnam. The deaths reported by Vietnam on August 12 are the first reported
human cases associated with this second wave of H5N1 infection among
poultry. CDC is in communication with WHO and will continue to monitor the
situation.

Enhanced U.S. Surveillance, Diagnostic Evaluation, and Infection Control
Precautions for Avian Influenza A (H5N1)

CDC recommends maintaining the enhanced surveillance efforts by state and
local health departments, hospitals, and clinicians to identify patients at
increased risk for avian influenza A (H5N1) that were issued by CDC on
February 3, 2004 (see
http://www.cdc.gov/flu/han020302.htm). Guidelines for enhanced
surveillance are:

Testing for avian influenza A (H5N1) is indicated for hospitalized patients
with:

Radiographically confirmed pneumonia,
acute respiratory distress syndrome (ARDS), or other severe respiratory
illness for which an alternate diagnosis has not been established, AND

History of travel within 10 days of
symptom onset to a country with documented H5N1 avian influenza in poultry
and/or humans (for a regularly updated listing of H5N1-affected countries,
see the OIE website at
http://www.oie.int/eng/en_index.htm and the WHO website at http://www.who.int/en/).

Testing for avian influenza A (H5N1) should
be considered on a case-by-case basis in consultation with state and local
health departments for hospitalized or ambulatory patients with:

Documented temperature of >38°C
(>100.4°F), AND

One or more of the following: cough,
sore throat, shortness of breath, AND

History of contact with poultry (e.g.,
visited a poultry farm, a household raising poultry, or a bird market)
or a known or suspected human case of influenza A (H5N1) in an
H5N1-affected country within 10 days of symptom onset.

Highly pathogenic avian influenza A (H5N1) is classified as a select agent
and must be worked with under Biosafety Level (BSL) 3+ laboratory
conditions. This includes controlled access double door entry with change
room and shower, use of respirators, decontamination of all wastes, and
showering out of all personnel. Laboratories working on these viruses must
be certified by the U.S. Department of Agriculture. CDC does not recommend
that virus isolation studies on respiratory specimens from patients who meet
the above criteria be conducted unless stringent BSL 3+ conditions can be
met. Therefore, respiratory virus cultures should not be performed in most
clinical laboratories and such cultures should not be ordered for patients
suspected of having H5N1 infection.

Clinical specimens from suspect A (H5N1) cases may be tested by PCR
[polymerase chain reaction] assays using standard BSL 2 work practices in a
Class II biological safety cabinet. In addition, commercial antigen
detection testing can be conducted under BSL 2 levels to test for influenza.

Specimens from persons meeting the above clinical and epidemiologic criteria
should be sent to CDC if

The specimen tests positive for
influenza A by PCR or by antigen detection testing, OR

PCR assays for influenza are not
available at the state public health laboratory.

Because the sensitivity of commercially
available rapid diagnostic tests for influenza may not always be optimal,
CDC also will accept specimens from persons meeting the above clinical
criteria even if they test negative by influenza rapid diagnostic testing if
PCR assays are not available at the state laboratory.

Requests for testing should come through the state and local health
departments, which should contact (404) 639-3747 or (404) 639-3591 and ask
for the epidemiologist on call before sending specimens for influenza A
(H5N1) testing.

(2 of 9)
August 16, 2004
CDC REPORTS ON STUDIES ASSESSING THE EFFECTIVENESS OF THE 2003-04
INFLUENZA VACCINE IN COLORADO

CDC published "Assessment of the Effectiveness of the 2003-04
Influenza Vaccine Among Children and Adults--Colorado, 2003" in
the August 13 issue of MMWR. Portions of the article and its
Editorial Note are reprinted below.

***********************

[The article's opening paragraph]
The 2003-04 influenza season was characterized by the early onset
of influenza activity, reports of severe illness, particularly in
children, and predominant circulation of an influenza A (H3N2)
virus strain that was antigenically different from the influenza A
(H3N2) vaccine strain. In 2003, a retrospective cohort study among
children and a case-control study among adults in Colorado were
conducted to provide preliminary data on the effectiveness of the
2003-04 influenza vaccine. This report summarizes the results of
those studies, which indicated vaccine effectiveness (VE) among
both adults and children, differing from results of a previous
study that did not indicate effectiveness among adults. . . .

[From the article's Editorial Note]
The findings from the two studies indicated that the influenza
vaccine had some effectiveness (25%-49% against nonlaboratory-confirmed
influenza and 38%-52% against laboratory-confirmed influenza) in
preventing illness during the 2003-04 influenza season, supporting
recommendations to continue influenza vaccination efforts despite
a suboptimal match between the predominant influenza A (H3N2)
circulating and vaccine strains. The effectiveness of the
inactivated influenza vaccine against laboratory-confirmed illness
among healthy adults aged <65 years is expected to be 70%-90% in
years when the vaccine and circulating strains are well matched.
The estimated 52% VE against laboratory-confirmed influenza among
adults with no high-risk conditions in this study was lower, but
still provided substantial health benefit. The study among
children aged 6-23 months provides further data that 2 doses of
vaccine (i.e., a dose of the current vaccine plus a primer dose)
are needed to optimize protection compared with a single dose.

Results from these studies differ from those of a study of health
care workers that did not find the 2003-04 influenza vaccine to be
effective against ILI [influenza-like illness]. However, the
health care worker study might have had an insufficient number of
subjects to detect low effectiveness against ILI compared with the
pediatric ILI study, which included approximately three times as
many subjects in a population expected to have a higher influenza
illness attack rate than adults. In addition, the more specific
outcome of medically attended, laboratory-confirmed influenza used
in the case-control study of persons aged 50-64 years was more
likely to find effectiveness, compared with the less
influenza-specific ILI outcome used in the health care worker
study. . . .

Influenza vaccine remains the primary means for the prevention of
influenza and its complications and can provide benefit even in
years when the influenza vaccine and circulating strains are not
matched optimally. Efforts to increase vaccination rates in groups
at high risk and their contacts are needed to reduce the burden of
influenza. In addition, vaccination with 2 doses of influenza
vaccine for children not vaccinated previously against influenza
is needed to maximize protection. For optimal assessment of
influenza VE, prospective studies should be conducted annually.

On August 11, the Journal of the American Medical Association (JAMA)
published "Contagiousness of Varicella in Vaccinated Cases: A
Household Contact Study." The article concluded in part that
"Under conditions of intense exposure, varicella vaccine was
highly effective in preventing moderate and severe disease and
about 80% effective in preventing all disease." The article
abstract is reprinted below.

**********************

Context: Limited data are available on the contagiousness of
vaccinated varicella cases.

Objectives: To describe secondary attack rates within households
according to disease history and vaccination status of the primary
case and household contacts and to estimate varicella vaccine
effectiveness.

Design, Setting, and Patients: Population-based, active varicella
surveillance project in a community of approximately 320,000 in
Los Angeles County, California, during 1997 and 2001. Varicella
cases were reported by childcare centers, private and public
schools, and health care clinicians and were investigated to
collect demographic, clinical, medical, and vaccination data.
Information on household contacts' age, varicella history, and
vaccination status was collected.

Main Outcome Measures: Varicella secondary attack rate among
household contacts; vaccine effectiveness using secondary attack
rates in unvaccinated and vaccinated children and adolescents.

Results: A total of 6,316 varicella cases were reported. Among
children and adolescents aged 1 to 14 years, secondary attack
rates varied according to age and by disease and vaccination
status of the primary case and exposed household contacts. Among
contacts aged 1 to 14 years exposed to unvaccinated cases, the
secondary attack rate was 71.5% if they were unvaccinated and
15.1% if they were vaccinated (risk ratio [RR], 0.21; 95%
confidence interval [CI], 0.15-0.30). Overall, vaccinated cases
were half as contagious as unvaccinated cases. However, vaccinated
cases with 50 lesions or more were similarly contagious as
unvaccinated cases, whereas those with fewer than 50 lesions were
only one-third as contagious (secondary attack rate, 23.4%; RR,
0.32 [95% CI, 0.19-0.53]). Vaccine effectiveness for prevention of
all disease was 78.9% (95% CI, 69.7%-85.3%); moderate disease, 92%
(50-500 lesions) and 100% (clinician visit); and severe disease,
100%.

Conclusions: Under conditions of intense exposure, varicella
vaccine was highly effective in preventing moderate and severe
disease and about 80% effective in preventing all disease.
Breakthrough varicella cases in household settings were half as
contagious as unvaccinated persons with varicella, although
contagiousness varied with numbers of lesions.

(4 of 9)
August 16, 2004
CDC REPORTS ON US MEASLES EPIDEMIOLOGY DURING 2001-03

CDC published "Epidemiology of Measles--United States, 2001-2003"
in the August 13 issue of MMWR. The article's opening paragraph is
reprinted below.

***********************

Measles is a highly infectious, acute viral illness that can cause
severe pneumonia, diarrhea, encephalitis, and death. To
characterize the epidemiology of measles in the United States
during 2001-2003, CDC analyzed data reported by state and local
health departments. This report summarizes the results of that
analysis, which indicated that no endemic measles virus is
circulating in the United States; however, imported measles cases
continue to occur and can result in limited indigenous
transmission. Maintaining immunity through high vaccination
coverage levels is essential to limit the spread of measles from
imported cases and prevent measles from becoming endemic.

(5 of 9)
August 16, 2004
CDC SEEKS PUBLIC'S COMMENTS ON ITS VACCINE SAFETY PROGRAM

CDC published "Notice to Readers: Public Comment Sought on CDC's
Vaccine Safety" in the August 13 issue of MMWR. It is reprinted
below in its entirety.

***********************

In consultation with outside stakeholders, the CDC has undertaken
a review of vaccine safety activities at CDC. As part of this
effort, the CDC is seeking public comments regarding the current
state of the agency's vaccine safety program and to identify ways
in which excellence in vaccine safety monitoring, research, and
communication can be maximized and sustained in the future.
Comments should focus on the objectives listed below:

Review the structure, function,
credibility, effectiveness, efficiency, and support of CDC's
vaccine safety program and assess how it can be maximized and
sustained.

Assess the capacity of the
program to provide comprehensive monitoring of the growing
number of vaccines.

Review the intramural and
extramural collaborative activities of the vaccine safety
program and determine their effectiveness and efficiency.

Assess additional steps CDC
can institute to enhance coordination with other federal
agencies and partners, including consumer and advocacy
groups.

Determine the optimal
organizational location for vaccine safety activities within
the CDC to ensure scientific objectivity, transparency, and
oversight while at the same time ensuring that program
priorities are appropriately established and are relevant to
the immunization program and other stakeholder needs.

CDC will post presentations of facts about
CDC's vaccine safety activities on the CDC website so that the public can
make informed comments about the objectives listed above. The link to the
objectives is at
http://www.cdc.gov/od/vaccsafe/comments.htm The links to the
presentations are also provided on the website.

We invite the public to review the available information and follow the
instructions for providing comments and input. The public comment period
will end on October 12, 2004.

If you have any questions or need more information, please email the
following address: vaccsafe@cdc.gov

(6 of 9)
August 16, 2004
MICHIGAN HAS DISTRIBUTED 300,000 ADULT IMMUNIZATION RECORD
CARDS--IAC URGES YOU TO DISTRIBUTE THEM, TOO!

The Michigan Department of Community Health must believe in
making it easy for Michigan adults to keep track of their
vaccination status. In the past few years, the department has
distributed more than 300,000 IAC adult immunization record
cards.

"We love the IAC adult immunization record cards," said
Rosemary Franklin, the immunization division's information and
education coordinator. Why? One big reason is that it gives
adult patients a PERMANENT record of their immunizations. At
times, this can be invaluable. For example, if a person
sustains a wound and is brought to a hospital emergency room
that has no access to vaccination records, the person can
refer to their immunization record card to find out their
tetanus-diphtheria vaccination status.

Another reason is that the canary-yellow card, which is small
enough to fit in a wallet, is easy to spot. "The card is
bright, easy to find, and virtually indestructible," Franklin
said. "One of my co-workers added a card to a load of laundry,
and it came out legible and intact!"

How to use the card
In addition to being a foolproof way to help patients keep
track of their vaccination status, the record card is an
inexpensive educational tool. The card lists seven vaccines
that all adults or certain adults should receive. Health care
professionals (HCPs) can use it during patient encounters to
discuss a patient's vaccination status with them. At the end
of the visit, the HCP gives the card to the patient and
encourages them to refer to it to find out when they're due
for their next Td booster, a pneumococcal vaccine dose, or
other vaccination.

Almost 2 million cards shipped
The Adult Immunization Record Card was developed by IAC in
collaboration with CDC and several state health departments.
Since introducing it in May 2002, IAC has shipped more than
1.8 million cards to health care providers across the United
States.

Cost and ordering information
The cost for one 250-count box is $30; two boxes (500 cards),
$55; three boxes (750 cards), $75; four boxes (1,000 cards),
$90. Additional pricing for larger quantities can be found on
the online order form (see link below). NOTE: THE FIRST ORDER
OF A 250-CARD BOX COMES WITH A 30-DAY MONEY-BACK GUARANTEE.

To order IAC's Adult Immunization Record Cards online
(including online with a purchase order), go to:https://www.immunize.org/adultizcards

If you have questions about IAC's Adult Immunization Record
Card, call us at (651) 647-9009, or email us at admin@immunize.org
(Use the same email address to receive sample cards.)
---------------------------------------------------------------

(7 of 9)
August 16, 2004
UPDATED: IAC REVISES EDUCATIONAL PIECES ON VACCINE STORAGE AND
HANDLING--JUST IN TIME FOR INFLUENZA VACCINATION SEASON

IAC recently made minor but significant changes to five
professional-education pieces on vaccine storage and handling.
The five updated pieces include checklists, temperature logs,
and other aids that simplify and take the guesswork out of
storage and handling. Information and links to the five pieces
follow:

"Maintaining the Cold Chain
During Transport," gives instructions for maintaining
inactivated and live-virus vaccines at the proper
temperature during transport.

To obtain a ready-to-copy (PDF) version of the updated
sheet, go to:
http://www.immunize.org/catg.d/p3049.pdf

"Checklist for Safe Vaccine
Handling and Storage," lists the 20 most important things to
do to safeguard your vaccine supply.

To obtain a ready-to-copy (PDF) version of the updated
sheet, go to:
http://www.immunize.org/catg.d/p3035chk.pdf

"Temperature Log for
Vaccines" (Fahrenheit or Celsius) has been expanded from two
pages to four. Each log has space for tracking refrigerator
and freezer temperatures for a month and also includes space
for maintaining a vaccine storage troubleshooting record.

In addition, IAC updated a one-page
checklist, "Suggested Supplies Checklist for Adult Immunization Clinic,"
that serves as a reminder of the medical supplies and other items needed to
set up an adult vaccination clinic.

(8 of 9)
August 16, 2004
COMING THIS WEEK: AUGUST 19 IS THE DATE FOR CDC'S SATELLITE
BROADCAST "IMMUNIZATION UPDATE 2004"

The live satellite broadcast and webcast "Immunization
Update 2004" will provide up-to-date information on the
rapidly changing field of immunization. Following is the
anticipated course content: new recommendations for
influenza vaccine, including routine vaccination of children
ages 6-23 months and expanded use of live attenuated
intranasal vaccine; pneumococcal conjugate vaccine shortage;
varicella vaccine; and vaccine safety issues.

Sponsored by CDC, the live broadcast is scheduled for August
19 from 9AM to 11:30AM ET. It will be rebroadcast later in
the day from noon to 2:30PM ET. Both broadcasts will feature
a live Q&A session in which participants nationwide can
interact with the course instructors via toll-free telephone
lines.

The program's intended audience includes physicians, nurses,
nurse practitioners, physician assistants, Department of
Defense paraprofessionals, pharmacists, and their colleagues
who either administer vaccines or set policy for their
offices, clinics, or communicable disease or infection
control programs. Private and public health care providers,
including pediatricians, family physicians, residents, and
medical and nursing students are encouraged to participate.

You DO NOT need to register to participate in the webcast.
ONLINE REGISTRATION IS REQUIRED TO RECEIVE CONTINUING
EDUCATION CREDITS. To register, go to:
http://www.phppo.cdc.gov/phtnonline

Pharmacists can earn continuing education credit through
their own online learning system. To register, pharmacists
should go to:
http://www.pharmacist.com

(9 of 9)
August 16, 2004
ACT NOW: AUGUST 20 IS THE DEADLINE FOR EARLY-BIRD
REGISTRATION FOR THE IMMUNIZATION REGISTRY CONFERENCE

August 20 is the early-bird registration deadline for the
5th Immunization Registry Conference. The conference will be
held October 18-20 at the Crowne Plaza Ravinia in Atlanta.
In addition, three preconference workshops, sponsored by the
American Immunization Registry Association (AIRA), are
planned for October 17 (for details, see final paragraph in
this article).

Expected to bring together more than 450 local, state,
federal, and private sector immunization registry partners,
the conference is intended to promote knowledge and
information about the development and use of immunization
registries. The conference will give participants
programmatic, technical, and scientific information that
will improve the use of immunization registries. It will
also provide a forum to build support for registries,
enhance collaboration, promote multiple and innovative uses
of registry data, explore alternative funding strategies,
and demonstrate registry successes.